Is family medicine residency too short and too urban?

A man with chest pains arrives at a small town family medicine clinic seeking help for a heart attack. Based on an assessment and the results of investigations available locally, the doctor suspects it’s a muscle problem rather than an issue with the heart itself. But with specialists and more sophisticated investigations several hours away, what to do next?

When Fraser Pollard encountered a situation like this, he did what in game show parlance might be called “phone a friend.” He reached out to a specialist he’d met during his training, seeking a reassuring second opinion.

“There’s just a lot of insecurity,” says Pollard, who finished his family medicine training in 2015 and now delivers comprehensive care at both his family practice and at the local hospital in Trenton, Ontario.

That feeling is not uncommon among new family physicians, and it’s fuelling discussion of whether family medicine residency should be expanded from two years to three to help newly minted physicians better cope with the myriad problems they might treat.

Canada has the shortest residency program for family medicine in the world, “with ever increasing expectations for service by family physicians,” says Nancy Fowler, executive director of Academic Family Medicine with the College of Family Physicians of Canada.

“What I see, looking at medical students finishing now, is that their knowledge base is so dramatically better than what mine was at the same stage, but what I don’t see – and the question really is why – is the confidence to go out and do stuff,” says John Soles, past president of the Society of Rural Physicians of Canada.

The question of how to build “clinical courage” – proceeding in the face of uncertainty and fear, as Soles defines it – is at the heart of the debate about expanding family medicine residency.

It’s also spurred recommendations to move some family medicine training out of urban teaching hospitals and into rural and remote settings, to give trainee physicians more experience practicing with limited technology or specialist support.

‘Learned helplessness’

While programs vary slightly depending on the medical school offering them, Canadian family medicine residents are mandated to complete at least 24 months of training after completing medical school. In 2012, Triple C Competency Based Curriculum training was introduced, giving trainee physicians exposure to common family medicine issues. That might include providing care in a hospital, maternity ward, palliative care or emergency department. The idea is to build skill through practical, hands-on experience.

Trends in medical training shift, although not always in sync with the realities of practice. Family medicine training has allowed for specialization, narrowing the comfort zone for many recent graduates. At the same time, lack of timely access to specialist care has left family physicians feeling as though they’re dealing with more diverse and complex cases, requiring more time and broader knowledge.

Worse, says Roger Strasser, dean of the Northern Ontario School of Medicine (NOSM), trainees with easy access to on-call specialists tend to rely on the specialist’s expertise, shortchanging their own education and leaving themselves vulnerable to burnout and a lack of confidence when they’re finally out on their own – especially if they work in rural or remote communities.

“New graduates learn what I describe as a learned helplessness. It’s about which specialist to send patients to, rather than taking care of the problem themselves,” Strasser says.

Patients in rural, remote or Indigenous communities tend to be older, poorer and sicker, and they remain underserved – Indigenous communities particularly. Although people living in rural or remote places make up nearly 20 percent of the country’s population, they’re served by just eight percent of the country’s physicians.

The skills needed to fill these care gaps aren’t necessarily being cultivated at urban teaching hospitals, where the caseload may be quite different to what might be encountered in a remote or rural setting, Strasser says.

“The mix of patients who actually make it into a teaching hospital have to be either very sick or have a rare condition or need a high tech intervention. Out of 1,000 people in a rural community, less than one would make it into a teaching hospital. But that’s where most medical students learn their clinical medicine,” he says.

Training or post-education support?

There’s certainly an appetite among new physicians for expanded learning. A 2016 paper published in Canadian Family Physician reported that the number of family medicine trainees choosing to extend their training has doubled, moving from 11 percent in 1995 to 21 percent in 2013.

Certificates of Added Competency that extend training by an additional year are available in five key areas, including geriatric care, palliative care, emergency medicine, family practice anesthesia and sport and exercise medicine.

With the exception of anesthesia training, most family medicine graduates who do this extra training do not go on to be comprehensive family physicians. Instead, they tend to focus their practice on their specialization.

Soles isn’t convinced that a third year of training is the answer.

“The question really is, if you extend training, will you increase you experiential base and confidence in such a way that it’s worth doing that? Would it generate more capable family practitioners who are willing to work in environments where they have to use a wider scope of practice?”

Pollard isn’t sure more training is the answer either. He sees mentorship as far more valuable.

“Whether you have five years or two years of training, there’s a big difference between being in a learning environment where a second opinion is easy to find, and being out on your own,” he says.

Ravi Sidhu, a vascular surgeon and associate dean of postgraduate medical education at the University of British Columbia, agrees.

“One of the barriers to having long-term success in rural and remote recruitment is the support and infrastructure you need once you’re practising,” he says. “I think that’s something we have to pay more attention to, as well as the training. They can be trained, but if they’re getting into settings where they’re not set up to succeed – whether rural, remote or urban – then that’s the issue.”

Success of training in rural or remote settings

There are those who say expanding family medicine residency without transforming it would make no difference to the number of graduates who elect to practice in rural or remote communities.

Strasser says NOSM provides Canadian evidence to show that recruiting rural or remote students and training them in a rural or remote environment helps encourage trainees to stay in rural or remote medicine.

Nearly two-thirds of all NOSM medical graduates choose family practice training, and 94 percent of physicians who complete undergraduate and postgraduate education are practicing in northern Ontario, says a June 2016 article written by Strasser.

Despite disagreements on whether a two year or three year family medicine residency program is best, virtually everyone agrees that the context of the training makes a difference.

“When I see students who come from peripheral sites, they have a different philosophy of training,” Soles says. “It’s more hands-on. They’re doing stuff as opposed to doing ‘scut work.’ We need to be looking at programs that are generating good, broad-spectrum generalists who are capable of stepping into rural practice.”

Strasser advocates early identification of students with the traits necessary to work in rural practice – including a rural upbringing, a positive rural experience as an undergraduate, targeted postgraduate exposure outside urban areas, and a stated preference for family medicine.

He also argues trainees should be given the chance to learn about the health problems that are prevalent in their intended destinations so they can tailor their skills to what’s needed.

“One thing we shouldn’t forget is, of all the rural docs, at least 30 percent of them have urban beginnings. They grew up urban and did urban training. They went rural and are successful. It doesn’t mean urban doesn’t belong in rural. We can’t ignore the urban folks,” says Braam de Klerk, a physician working in Inuvik and a past-president of the Society of Rural Physicians of Canada.

De Klerk offers Australia as a worthwhile example. Over the past 10 years, rural training programs have been established in every state and territory. That’s ledto investment in teaching facilities, information technology, videoconferencing and student accommodation in small rural towns and new opportunities for rural clinicians to practice, teach and conduct research.

While de Klerk is supportive of extra training, he also takes a realistic view.

“There’s no course in clinical courage,” he says. “You get it by taking your best guess and doing it. That’s the way you learn. Learn by mistakes and by successes.”

Rural Road Map

In the meantime, a recent pan-Canadian Summit on rural medicine saw the launch of the Rural Road Map for Action. It outlines four paths for improving rural family medicine, including:

recruitment of more students from rural, remote or Indigenous communities,

greater flexibility and hands-on, rural-relevant training that would allow students to meet the needs of communities,

improved technology and other infrastructure designed for better care, and

establishing a rural research agenda to help plan for both the medical and human resource needs of rural, remote and Indigenous communities.

“We still have more work to do,” Strasser says. “We have to counter the perception that going rural is a second class or lesser standard. There are a whole lot of other elements. It’s not just about education and training, but about reputation, recognition and resources.”

Soles says perfection shouldn’t become the enemy of progress.

“There are always going to be gaps in their knowledge, in their experience,” he says. “You can’t do everything, you can’t see everything. At some point, you’re going to have to say, okay, this is a product that’s going to evolve further, but at this point, we can put them out in the woods and they’re capable of doing things, capable of looking up something if they don’t know. Sometimes, even when you’re not the best person to do this, you’re the only one available and therefore you’re going to have to do it.”

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7 comments

Wayne WestonApril 1st, 2017 at 4:58 pm

I agree with the 4 paths for improving rural family medicine. In addition, a program of structured CME for the first few years in practice, tailored to the needs of the community and supported by mentorship might be better than a 3rd year of residency. But, one challenge that is mentioned too infrequently is the need for better training for managing patients with mental illness. And we seem to be in the middle of an epidemic of mental illness. Learning good skills in therapy & counseling requires close supervision and feedback that is hard to get in CME programs.

I am a rural physician doing ER and obs for 17 years. The CME I was funded to do by the Ontario gov’t helped me greatly for 15 years: I was supported to keep my ACLS, ALARM, ATLS, NRP, PALS all up to date. This financial support (for travel, accomodations, the course fees AND a daily stipend for being out of the office) helped me get out of Dodge, network, and keep my skills in my rural area top quality. I recommend re-instating CME funding for rural physicians.

While I feel family medicine residency is too short, I’m astonished at how quickly a nurse practitioner can be trained (2 years of education after practicing as a registered nurse for 4 years) with relatively the same scope of practice.

I worry about the unintended consequences of extending FamMed training. Post-education support is absolutely necessary though.

Even if the capacity was there to extend training by a year (and I seriously doubt there is), it would effectively remove more than 1000 family doctors from independent practice. This is what happened 25 years ago when licensure after a 1-year internship was phased out, and it created the family doctor shortage that made rural recruitment even harder. If you couple extension of training with the work patterns of the current generation of family docs (many more women taking mat leave, decrease in hours, reduced OB and hospital work), it would make a looming human resource problem – waning interest in family medicine – far worse and almost overnight.

I learned more in my first year of independent practice than I did in most of residency. No amount of training is going to take clinical uncertainty away, and even the most experienced of us miss things and make mistakes. Residency’s purpose is to train doctors to competency, not mastery.

In Calgary, medical school is three years and then family residency is 2 years. Please, someone explain how 4 years of medical school and 3 years of family practice residency in that states is crammed into what Calgary trainees get? How can it be equivalent?

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